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					Firefighter I                     Basic Pre-Hospital Emergency Medical Care for Firefighters




                         Chapter 21
                Basic Pre-Hospital Emergency
                 Medical Care for Firefighters

                               Lesson Goal
After completing this lesson, the student shall be able to provide basic pre-
hospital emergency medical care for firefighters following the policies and
procedures set forth by the authority having jurisdiction (AHJ).

                                Objectives
Upon successful completion of this lesson, the student shall be able to:
  1.   Discuss the importance of body substance isolation (BSI).
  2.   Describe the components of personal protective equipment.
  3.   Discuss diseases of concern.
  4.   Describe laws that relate to infection control.
  5.   Explain the importance of immunizations.
  6.   Describe the physiological aspects of stress.
  7.   Describe types of stress reactions.
  8.   Summarize causes of stress.
  9.   List signs and symptoms of stress.
 10.   Explain various ways to deal with stress.
 11.   Describe scene safety considerations at hazardous materials
       incidents and rescue operations.
 12.   Describe actions required when responding to scenes involving
       violent or dangerous situations.
 13.   Discuss the circulatory system.
 14.   List the links in the chain of survival.
 15.   Explain actions to be taken before resuscitation.
 16.   Discuss rescue breathing.


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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



  17.           Describe the steps of cardiopulmonary resuscitation (CPR).
  18.           Describe the CPR techniques for an infant patient.
  19.           Describe the CPR techniques for a child patient.
  20.           Describe the CPR techniques for an adult patient.
  21.           Discuss indications of effective CPR and when CPR may be
                interrupted.
  22.           Summarize when not to begin or to terminate CPR.
  23.           Summarize actions taken when clearing an airway obstruction.
  24.           Describe the main components of the circulatory system.
  25.           Differentiate between arterial, venous, and capillary bleeding.
  26.           Describe the steps for controlling external bleeding.
  27.           Discuss internal bleeding.
  28.           Describe types of shock.
  29.           Describe the signs of shock.
  30.           Describe the steps for managing shock.




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Firefighter I                         Basic Pre-Hospital Emergency Medical Care for Firefighters



                               Instructor Information
This is the lesson covering basic pre-hospital medical care for the
Firefighter I course. This lesson covers the basic principles of body
substance isolation (BSI) and the protective clothing used by responders.
This lesson also covers stress, scene safety, and the basics of the
circulatory system. In-depth information is included on resuscitation,
rescue breathing, and cardiopulmonary resuscitation (CPR). Finally,
different types of bleeding and the signs and symptoms of shock are
described.

Important instructor information is provided in shaded boxes throughout
the lesson plan. Carefully review the instructor information before
presenting the lesson. Use this lesson as an introduction to the emergency
medical care that may be performed on the emergency scene.


                                   Methodology
This lesson uses lecture, discussion. The level of learning is
comprehension.




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Firefighter I                           Basic Pre-Hospital Emergency Medical Care for Firefighters




                    Estimated Total Time: 5 hours 45 minutes
Classroom teaching/written evaluation:             5 hours 45 minutes



    Time                         Section/Activity                                  Pages

10 min.            Section I: Introduction to Chapter 21

40 min.            Section II: Infection Control                               1004-1014

20 min.            Section III: Emotional Stress                               1014-1018

20 min.            Section IV: Scene Safety                                    1018-1022

40 min.            Section V: Introduction to Basic Cardiac Life               1022-1030
                   Support

15 min.            Section VI: Rescue Breathing                                1030

30 min.            Section VII: CPR                                            1031-1037

25 min.            Section VIII: Clearing Airway Obstructions                  1037-1041

40 min.            Section IX: Bleeding Control                                1041-1050

15 min.            Section X: Shock                                            1050-1053

15 min.            Section VII: Summary and Review

15 min.            Chapter 21 Quiz

60 min.            Chapter 21 Test

                                      Audiovisuals
   Visuals 21.1 to 21.90 (PowerPoint® Presentation)

                                      Evaluation
   Chapter 21 Quiz
   Chapter 21 Test


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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters




Section I: Introduction to Chapter 21                                                   10 min.

                               I.    INTRODUCTION TO CHAPTER 21
                                     A.    Lesson Goal

                               Instructor Note: Briefly review the lesson goal.
                               Emphasize that the purpose of this lesson is to
                               familiarize students with basic pre-hospital
                               emergency care.

                                           1. Chapter 21 lesson goal — After
                                              completing this lesson, the student
                                              shall be able to provide basic pre-
                                              hospital emergency medical care for
                                              firefighters following the policies and
                                              procedures set forth by the authority
                                              having jurisdiction (AHJ).

                                     B.    Objectives

                                           1. Discuss the importance of body
                                              substance isolation (BSI).

                                           2. Describe the components of personal
                                              protective equipment.

                                           3. Discuss diseases of concern.

                                           4. Describe laws that relate to infection
                                              control.

                                           5. Explain the importance of
                                              immunizations.

                                           6. Describe the physiological aspects of
                                              stress.



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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                7. Describe types of stress reactions.

                                8. Summarize causes of stress.

                                9. List signs and symptoms of stress.

                                10. Explain various ways to deal with
                                    stress.

                                11. Describe scene safety considerations
                                    at hazardous materials incidents and
                                    rescue operations.

                                12. Describe actions required when
                                    responding to scenes involving
                                    violent or dangerous situations.

                                13. Discuss the circulatory system.

                                14. List the links in the chain of survival.

                                15. Explain actions to be taken before
                                    resuscitation.

                                16. Discuss rescue breathing.

                                17. Describe the steps of
                                    cardiopulmonary resuscitation (CPR).

                                18. Describe the CPR techniques for an
                                    infant patient.

                                19. Describe the CPR techniques for a
                                    child patient.

                                20. Describe the CPR techniques for an
                                    adult patient.

                                21. Discuss indications of effective CPR
                                    and when CPR may be interrupted.



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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                22. Summarize when not to begin or to
                                    terminate CPR.

                                23. Summarize actions taken when
                                    clearing an airway obstruction.

                                24. Describe the main components of
                                    the circulatory system.

                                25. Differentiate between arterial,
                                    venous, and capillary bleeding.

                                26. Describe the steps for controlling
                                    external bleeding.

                                27. Discuss internal bleeding.

                                28. Describe types of shock.

                                29. Describe the signs of shock.

                                30. Describe the steps for managing
                                    shock.




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Firefighter I                              Basic Pre-Hospital Emergency Medical Care for Firefighters




Section II: Infection Control                                                            40 min.

                               II.    INFECTION CONTROL
                               Instructor Note: The purpose of this section is to
                               introduce students to the basics of infection control,
                               including body substance isolation (BSI) and the
                               protective gear used to ensure infection control.

p. 1004                        Objective 1 — Discuss the importance of
                               body substance isolation (BSI).
                                      A.    Pathogens

                                            1. Organisms that cause infection

                                            2. May be spread through the air or by
                                               contact with blood and other body
                                               fluids

                                            3. Bloodborne pathogens — Can be
                                               contracted by exposure to the
                                               patient’s blood and sometimes other
                                               body fluids, especially when they
                                               come in contact with an open wound
                                               or sore on the firefighter’s hands,
                                               face, or other exposed parts
                                               including mucous membranes, such
                                               as those in the nose, mouth, or eyes

                                            4. Airborne pathogens

                                                 a. Spread by tiny droplets sprayed
                                                    during breathing, coughing, or
                                                    sneezing




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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     b. Can be absorbed through the
                                        eyes or when inhaled

                                5. All body fluids must be considered
                                   infectious and appropriate
                                   precautions taken for all patients at
                                   all times.

                                6. Body Substance Isolation (BSI)
                                   precautions

                                     a. Equipment and procedures that
                                        protect responders from the
                                        blood and body fluids of the
                                        patient

                                     b. Also referred to as infection
                                        control

                                     c. Requirements

                                          i.   Employers — Must develop a
                                               written exposure control plan
                                               and must provide emergency
                                               care providers during training,
                                               immunizations, and proper
                                               personal protective
                                               equipment (PPE) to prevent
                                               transmission of disease

                                          ii. Employee — Participate in
                                              training and follow the
                                              exposure control plan

                                          iii. Agencies — Must have a
                                               written policy in place in the
                                               event of an exposure to
                                               infectious substances



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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters



                                                d. Federal legislation has made it
                                                   possible for emergency care
                                                   providers to be notified if a
                                                   patient with whom they have had
                                                   potentially infectious contact
                                                   turns out to be infected by a
                                                   disease or virus such as
                                                   tuberculosis (TB), hepatitis, or
                                                   HIV.

pp. 1005-1006                  Objective 2 — Describe the components
                               of personal protective equipment.
                                     A.    Protective gloves

                                           1. Latex, vinyl, or other synthetic
                                              gloves should be used whenever
                                              there is the potential for contact with
                                              blood or other body fluids.

                               Ask Students: When should gloves be changed?


                               Briefly discuss the answers with students.
                               Emphasize that gloves should be changed after
                               each and every patient, even when working with as
                               little as two patients at a time.

                                           2. Allergies to latex — Vinyl and non-
                                              latex gloves should be used if the
                                              firefighter or patient is allergic to
                                              latex.

                                           3. Heavyweight, tear-resistant gloves
                                              should be used to clean the
                                              ambulance and soiled equipment.




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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                               B.    Handwashing

                                     1. When soap and water is available,
                                        vigorous handwashing is
                                        recommended.

                                     2. Wash hands after each patient
                                        contact and whenever they become
                                        visibly soiled.

                                     3. Alcohol-based hand cleaners

                                          a. Considered effective by the CDC,
                                             except when hands are visibly
                                             soiled or when anthrax is present

                                          b. Often available when soap and
                                             water are not

                                          c. Help kill microorganisms

                               C.    Eye protection

                                     1. Prevent splashing, spattering, or
                                        spraying fluids form entering the
                                        body through these membranes

                                     2. Should provide protection from the
                                        front and sides

                                     3. Types

                                          a. Goggles

                                          b. Clip-on side protectors for
                                             prescription eyeglasses

                                          c. Protective eyewear that
                                             resembles eyeglasses



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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     D. Masks

                                           1. In cases where blood or fluid may
                                              splatter, a surgical-type mask should
                                              be worn.

                                           2. In cases where tuberculosis is
                                              suspected, an N-95 or high efficiency
                                              particulate air (HEPA) respirator
                                              should be used.

                                           3. If the patient is suspected of having
                                              an infection spread by droplets, a
                                              surgical-type mask may be placed on
                                              the patient if alert and cooperative.

                               Instructor Note: Remind students that caution
                               should be used when covering a patient’s mouth
                               and nose with a mask of any kind. The mask
                               reduces their ability to visualize and protect the
                               airway. Responders should monitor respirations and
                               be prepared to remove the mask if necessary.

                                     E.    Gowns

                                           1. Worn to protect clothing and bare
                                              skin from spilled or splashed fluids

                                           2. Should be used with gloves, eye
                                              protection, and a mask




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters




pp. 1007-1009                  Objective 3 — Discuss diseases of
                               concern.
                                    A.    Hepatitis

                                          1. An infection that causes an
                                             inflammation of the liver

                                          2. Forms

                                               a. Hepatitis A — Acquired through
                                                  contact with stool; is especially
                                                  hardy

                                               b. Hepatitis B

                                                    i.   Has been found to live for
                                                         many days in dried blood
                                                         spills, posing a risk of
                                                         transmission long after many
                                                         other viruses would have died

                                                    ii. Can be deadly

                                                    iii. Has no cure, but an effective
                                                         vaccine is available and is
                                                         generally required of health
                                                         care workers

                                               c. Hepatitis C — Acquired through
                                                  blood exposure; there is no
                                                  vaccination

                                               d. Hepatitis Delta




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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     B.    Tuberculosis (TB)

                                           1. Sometimes settles in the lungs and
                                              can be fatal

                                           2. Was thought to be largely
                                              eradicated, but made a comeback in
                                              the 1980s

                                           3. Highly contagious

                                           4. Can spread through the air

                                           5. It is safest to presume that a patient
                                              with a productive cough could be the
                                              result of TB and necessary
                                              respiratory precautions should be
                                              taken.

                               Instructor Note: Remind students that TB is a
                               very hearty bacteria. A thorough decontamination
                               of all equipment should be performed immediately
                               after contact with an infected patient.

                                     C.    AIDS (Acquired immune deficiency
                                           syndrome)

                                           1. The name for a set of conditions that
                                              result when the immune system has
                                              been attacked by HIV (human
                                              immunodeficiency virus) and
                                              rendered unable to combat certain
                                              infections adequately

                                           2. Has no cure




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Firefighter I                    Basic Pre-Hospital Emergency Medical Care for Firefighters



                                  3. Does not survive well outside of the
                                     human body, so presents far less
                                     risk to health-care workers than
                                     hepatitis and TB

                                  4. Routes of exposure are limited to
                                     direct contact with blood by way of
                                     open wounds, intravenous drug use,
                                     unprotected sexual contact, or blood
                                     transfusions.

                                  5. Puncture wounds into which HIV is
                                     introduced

                                       a. Potential routes of infection

                                       b. Only result in infection less than
                                          half of one percent of the time

                               D. Emerging diseases and conditions

                                  1. West Nile virus

                                       a. Spread by mosquitoes

                                       b. Causes flu-like symptoms in mild
                                          cases and infections of the brain
                                          and meninges in severe cases

                                  2. Severe Acute Respiratory Syndrome
                                     (SARS)

                                       a. Appears to be a new virus

                                       b. Appears to be spread through
                                          respiratory droplets, by coughing,
                                          sneezing, or touching something
                                          contaminated and then touching
                                          the nose or eyes



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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



                                               c. A respiratory virus with
                                                  symptoms that include fever, dry
                                                  cough, and difficulty breathing

                                               d. Protection

                                                    i.   Frequent hand washing

                                                    ii. Use of gloves, gowns, eye
                                                        protection, and an N-95
                                                        respirator

pp. 1009-1013                  Objective 4 — Describe laws that relate
                               to infection control.
                                    A.    Occupational Exposure to
                                          Bloodborne Pathogens

                                          1. OSHA standard that took effect in
                                             1992

                                          2. Mandates measures employers of
                                             emergency responders must take to
                                             protect employees who are likely to
                                             be exposed to blood and other body
                                             fluids

                                          3. Basic principle — Infection control is
                                             a joint responsibility between
                                             employer and employee.

                                               a. Employers must provide training,
                                                  protective equipment, and
                                                  vaccinations to employees who
                                                  are subject to exposure in their
                                                  jobs.




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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     b. Employees must participate in an
                                        infection exposure control plan
                                        that includes training and proper
                                        workplace practices.

                                4. Critical elements

                                     a. Infection exposure control plan

                                          i.   Identifies and documents job
                                               classifications and tasks in
                                               which there is the possibility
                                               of exposure to potentially
                                               infectious body fluids

                                          ii. Must outline a schedule of
                                              how and when the
                                              bloodborne pathogen
                                              standards will be
                                              implemented

                                          iii. Must include identification of
                                               the methods used for
                                               communicating hazards to
                                               employees, post-exposure
                                               evaluation, and follow-up

                                     b. Adequate education and training
                                        — Firefighters must be provided
                                        with training that includes
                                        general explanations of how
                                        diseases are transmitted, uses
                                        and limitations of practices that
                                        reduce or prevent exposure, and
                                        procedures to follow if exposure
                                        occurs.




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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     c. Hepatitis B vaccination — Must
                                        be made available free of charge
                                        and at a reasonable time and
                                        place

                                     d. Personal protective equipment

                                          i.   Must be of a quality that will
                                               not permit blood or other
                                               infectious materials to pass
                                               through or reach a
                                               firefighter’s work clothes,
                                               street clothes,
                                               undergarments, skin, eyes,
                                               mouth, or other mucous
                                               membranes

                                          ii. Must be provided by the
                                              employer to the firefighter at
                                              no cost

                                               Examples: Protective gloves,
                                               face shields, masks,
                                               protective eyewear, gowns
                                               and aprons, plus bag-valve
                                               masks, pocket masks, and
                                               other ventilation devices

                                     e. Methods of control

                                          i.   Engineering controls remove
                                               potential infectious disease
                                               hazards or separate the
                                               firefighter from exposure.

                                               Examples: Pocket masks,
                                               disposable airway equipment,
                                               and puncture-resistant needle
                                               containers.

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                                          ii. Work practice controls
                                              improve the manner in which
                                              a task is performed to reduce
                                              risk of exposure.

                                              Examples: Proper and safe
                                              use of personal protective
                                              equipment, proper handling,
                                              labeling, and disposal of
                                              contaminated materials, and
                                              proper washing and
                                              decontamination practices.

                                     f. Housekeeping — Clean and
                                        sanitary conditions of the
                                        emergency response vehicles and
                                        work sites are the responsibility
                                        of both the firefighter and the
                                        employer.

                                          Examples: Proper handling and
                                          proper decontamination of work
                                          surfaces, equipment, laundry,
                                          and other materials

                                     g. Labeling — Of containers used to
                                        store, transport, or ship blood
                                        and other potentially infectious
                                        materials, including the use of
                                        the biohazard symbol

                                     h. Post-exposure evaluation and
                                        follow-up — Firefighters must
                                        immediately report suspected
                                        exposure incidents that result
                                        from the performance of an
                                        employee’s duties.




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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                               B.    Ryan White Comprehensive AIDS
                                     Resources Emergency (CARE) Act

                                     1. A federal act that applies to all 50
                                        states

                                     2. Mandates a procedure by which
                                        emergency response personnel can
                                        seek to find out if they have been
                                        exposed to potentially life-
                                        threatening diseases while providing
                                        patient care

                                     3. Requires every state’s public health
                                        officer to designate an official within
                                        every emergency response
                                        organization to act as a ―designated
                                        officer.‖ This officer is responsible
                                        for gathering facts surrounding
                                        possible emergency responder
                                        airborne or bloodborne infectious
                                        disease exposures.

                                     4. Defines two notification systems for
                                        infectious disease exposure

                                          a. Airborne disease exposure —
                                             Responders will be notified by
                                             their designated officer when
                                             they have been exposed to an
                                             airborne disease.

                                          b. Bloodborne or other infectious
                                             disease exposure — Responders
                                             may submit a request for a
                                             determination as to whether or
                                             not they were exposed to
                                             bloodborne or other infectious
                                             disease.


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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     5. Does not empower hospitals to test
                                        patients for bloodborne diseases at
                                        the request of the emergency worker
                                        or designated officer; they can only
                                        review the patient’s medical records
                                        to see if evidence of a bloodborne or
                                        other disease exists

                               C.    Tuberculosis Compliance Mandate

                                     1. Describes the selection and proper
                                        use of different kinds of respirators
                                        including those classified as N-95 or
                                        HEPA

                                     2. Firefighters should learn to recognize
                                        situations in which the potential of
                                        exposure to TB exists.

                                          a. Those at greatest risk – Those
                                             who have suppressed immune
                                             systems

                                          b. Signs and symptoms – Productive
                                             cough and/or coughing up blood,
                                             weight loss and loss of appetite,
                                             lethargy and weakness, night
                                             sweats, and fever

                                     3. An N-95 or NEPA respirator should
                                        be used when:

                                          a. Caring for patients suspected of
                                             having TB — High-risk areas
                                             include correctional institutions,
                                             homeless shelters, long-term
                                             care facilities for the elderly, drug
                                             treatment centers.



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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



                                               b. Transporting an individual from
                                                  such a setting in a closed vehicle
                                                  — Keep the windows of the
                                                  ambulance open and set the
                                                  heating and air conditioning
                                                  system on the non-recirculating
                                                  cycle.

                                               c. Performing high-risk procedures
                                                  such as endotracheal suctioning
                                                  and intubation

pp. 1013-1014                  Objective 5 — Explain the importance of
                               immunizations.
                                    A.    Immunizations

                                          1. Immunizations against many
                                             diseases are available.

                                          2. An immunization to prevent hepatitis
                                             B may be available through the fire
                                             department, a local physician, or the
                                             local health department.

                                          3. There is no immunization against
                                             tuberculosis, but a test called a
                                             purified protein derivative (PPD) test
                                             can detect exposure.




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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters




Section III: Emotional Stress                                                           20 min.

                               III. EMOTIONAL STRESS
                               Instructor Note: The purpose of this section is to
                               describe the aspects, types, causes, and signs and
                               symptoms of stress.

pp. 1014-1015                  Objective 6 — Describe the
                               physiological aspects of stress.
                                     A.    Physiological aspects of stress

                                           1. Stress — A state of physical and/or
                                              psychological arousal to a stimulus

                                           2. Stress is a normal part of life and,
                                              when managed appropriately, does
                                              not have to pose a threat to well-
                                              being.

                                           3. The body’s response to stress
                                              (general adaptation syndrome)

                                           4. First stage — Alarm reaction

                                                a. Sympathetic nervous system
                                                   increases its activity in what is
                                                   known as the ―fight or flight‖
                                                   syndrome

                                                b. Pupils dilate, heart rate
                                                   increases, bronchial passages
                                                   dilate




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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     c. Blood sugar increase, digestive
                                        system slows, blood pressure
                                        rises, blood flow to the skeletal
                                        muscles increases

                                     d. Endocrine system produces more
                                        cortisol, a hormone that
                                        influences metabolism and
                                        immune response and is critical
                                        in the body’s ability to adapt to
                                        and cope with stress

                                5. Second stage — Stage of resistance

                                     a. Body systems return to normal
                                        functioning

                                     b. Physiologic effects of sympathetic
                                        nervous system stimulation and
                                        excess cortisol are gone

                                     c. Stimulus is adapted to and no
                                        longer produces stress

                                     d. Contributors to ability to cope —
                                        Physical and mental health,
                                        education, experiences, and
                                        support systems

                                6. Third stage — Exhaustion

                                     a. Occurs when exposure to a
                                        stressor is prolonged or the
                                        stressor is particularly severe

                                     b. Adrenal glands enlarge, lymph
                                        nodes atrophy, and gastric ulcers
                                        bleed



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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



                                               c. Body loses the ability to resist or
                                                  adapt to the stressor and may
                                                  become seriously ill as a
                                                  consequence

                                               d. Does not happen often

pp. 1015-1017                  Objective 7 — Describe types of stress
                               reactions.
                                    A.    Acute stress reaction

                                          1. Often linked to catastrophes, such as
                                             a large-scale natural disaster, a
                                             plane crash, or a coworker’s line-of-
                                             duty death or injury

                                          2. Signs and symptoms

                                               a. Will develop simultaneously or
                                                  within a very short time following
                                                  the incident

                                               b. May involve any one or a
                                                  combination of physical,
                                                  cognitive, emotional, or
                                                  behavioral functions

                                               c. Signs that this particular situation
                                                  is overwhelming a person’s ability
                                                  to cope and perform effectively




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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                                          d. Some may require immediate
                                             intervention from a physician or
                                             mental health professional. Any
                                             sign or symptom that indicates
                                             an acute medical problem or an
                                             acute psychological problem
                                             usually demand immediate
                                             corrective action.

                               B.    Delayed stress reaction

                                     1. Also known as post-traumatic stress
                                        disorder (PTSD)

                                     2. Can be triggered by a specific
                                        incident

                                     3. Signs and symptoms

                                          a. May not become evident until
                                             days, months, or even years later

                                          b. Include flashbacks, nightmares,
                                             feelings of detachment,
                                             irritability, sleep difficulties, or
                                             problems with concentration or
                                             interpersonal relationships

                                     4. May lead to drug and alcohol abuse

                                     5. Requires intervention by a mental
                                        health professional




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                               C.    Cumulative stress reaction

                                     1. Not triggered by a single critical
                                        incident, but instead from sustained,
                                        recurring low-level stressors

                                     2. Develops over a period of years

                                     3. May begin subtly and present as
                                        vague anxiety, progressing to
                                        boredom and apathy, and a feeling
                                        of emotional exhaustion

                                     4. May progress into physical
                                        complaints, significant sleep
                                        disturbances, loss of emotional
                                        control, irritability, withdrawal from
                                        others, and increasing depression.

                                     5. May result in manifestations such as
                                        migraines, increased smoking or
                                        alcohol intake, loss of sexual drive,
                                        poor interpersonal relationships,
                                        deterioration in work performance,
                                        limited self control, and significant
                                        depression

                                     6. May present as physical illness,
                                        uncontrollable emotions,
                                        overwhelming physical and
                                        emotional fatigue, severe
                                        withdrawal, paranoia, or suicidal
                                        thoughts




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters




p. 1017                        Objective 8 — Summarize causes of
                               stress.
                                    A.    Causes of stress

                                          1. Multiple-casualty incidents — Single
                                             incidents in which there are multiple
                                             patients

                                               Examples: Motor-vehicle crash in
                                               which two drivers and a passenger
                                               are involved, hurricane that causes
                                               the injury of hundreds of people

                                          2. Calls involving infants and children

                                               Examples: Serious injuries, SIDS

                                          3. Severe injuries

                                               Examples: Amputations, deformed
                                               bones, deep wounds, violent death

                                          4. Abuse and neglect

                                          5. Death of a coworker

                                    B.    Stress may also stem from a
                                          combination of factors, including
                                          problems in one’s personal life.




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters




pp. 1017-1018                  Objective 9 — List signs and symptoms
                               of stress.
                                    A.    Types of stress

                                          1. Eustress — A positive form of stress
                                             that helps people work under
                                             pressure and respond effectively

                                          2. Distress — Is negative and can
                                             happen when the stress of a scene
                                             becomes overwhelming

                                    B.    Signs and symptoms of stress

                                          1. Irritability with family, friends, and
                                             coworkers

                                          2. Inability to concentrate

                                          3. Changes in daily activities

                                          4. Anxiety

                                          5. Indecisiveness

                                          6. Guilt

                                          7. Isolation

                                          8. Loss of interest in work




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters




p. 1018                        Objective 10 — Explain various ways to
                               deal with stress.
                                    A.    Lifestyle changes

                                          1. Develop more healthful and positive
                                             dietary habits.

                                               a. Avoid fatty foods and increase
                                                  carbohydrate intake.

                                               b. Reduce consumption of alcohol
                                                  and caffeine.

                                          2. Exercise.

                                               a. Helps burn off stress

                                               b. Helps deal with the physical
                                                  aspects of a firefighter’s
                                                  responsibilities

                                          3. Devote time to relaxing.

                                    B.    Changes to professional life

                                          1. Consider requesting a change to a
                                             different location that offers a lighter
                                             call volume or different types of
                                             calls.

                                          2. Consider a shift change that allows
                                             more time with family and friends.

                                          3. Seek help from professionals that
                                             deal with firefighters or others
                                             experiencing stress.




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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters




Section IV: Scene Safety                                                                20 min.

                               IV.   SCENE SAFETY
                               Instructor Note: The purpose of this section is to
                               discuss scene safety considerations at hazardous
                               materials and rescue operations.

pp. 1018-1019                  Objective 11 — Describe scene safety
                               considerations at hazardous materials
                               incidents and rescue operations.
                                     A.    Scene safety

                                           1. At hazardous materials incidents

                                                a. When there is an accident
                                                   involving hazardous materials or
                                                   when containers begin to leak, a
                                                   hazardous materials incident may
                                                   occur, which will pose serious
                                                   dangers for firefighters as well as
                                                   for others who are in the vicinity.

                                                b. The primary rule is to maintain a
                                                   safe distance from the source of
                                                   the hazardous material.

                                                c. Make sure the ambulance or
                                                   other emergency vehicle is
                                                   equipped with binoculars.

                                                d. Binoculars will help identify
                                                   placards, which are placed on
                                                   vehicles, structures, and storage
                                                   containers when they hold
                                                   hazardous materials.


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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     e. These placards use coded colors
                                        and identification numbers that
                                        are listed in the Emergency
                                        Response Guidebook (ERG).
                                          i.   Should be placed in every
                                               vehicle that responds to or
                                               may respond to a hazardous
                                               materials incident.

                                          ii. Provides important
                                              information about the
                                              properties of the dangerous
                                              substance as well as
                                              information on safe distances,
                                              emergency care, and
                                              suggested procedures in the
                                              event of spills or fire

                                     f. Recognize potential problems.

                                     g. Take initial actions for personal
                                        safety and the safety of others.

                                     h. Notify an appropriately trained
                                        hazardous materials response
                                        team.

                                          i.   Made up of specially trained
                                               technicians who will
                                               coordinate the safe approach
                                               and resolution of the incident

                                          ii. Wear a special suit that
                                              protects the skin




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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters



                                                     iii. Must wear a self-contained
                                                          breathing apparatus (SCBA)
                                                          for protection from poisonous
                                                          gases, dust, and fumes

                                                i.   Do NOT take any actions other
                                                     than those aimed at protecting
                                                     self, patients, and bystanders at
                                                     the scene.

                                           2. At rescue operations

                                                a. Ensure that appropriate
                                                   assistance is requested early in
                                                   the call.

                                                b. Never perform acts not properly
                                                   trained to do.

                                                c. Do the best to secure the scene,
                                                   then stand by for the specialists.

                               Instructor Note: Explain to students that patients
                               who are still able to walk will most likely attempt to
                               reach responders. If these patients cannot be
                               contained, they should at least be hosed off before
                               any contact is made by emergency responders.
                               Responders should be sure to explain to the patient
                               what they are doing and why they are doing it.




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



pp. 1019-1022                  Objective 12 — Describe actions
                               required when responding to scenes
                               involving violent or dangerous
                               situations.
                                    A.    First priority — Be certain that the
                                          scene is safe.

                                          1. If the dispatcher knows that violence
                                             is or potentially may be present, he
                                             or she will advise not to approach
                                             the scene until it is safe.

                                          2. It is the responsibility of the police to
                                             secure a scene and make it safe for
                                             fire service duties to be performed.

                                    B.    Plan

                                          1. Wear safe clothing.

                                               a. Nonslip shoes

                                               b. Practical clothing

                                               c. Reflective clothing (if near traffic)

                                          2. Prepare equipment so it is not
                                             cumbersome.

                                          3. Carry a portable radio whenever
                                             possible.

                                          4. Decide on safety roles — Firefighters
                                             not directly involved with patient
                                             care should actively observe for such
                                             things as weapons, mechanisms of
                                             injury, medications, and other
                                             important information.


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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                               C.    Observe

                                     1. The neighborhood while looking for
                                        house or building numbers

                                     2. The scene when approaching

                                     3. Violence

                                     4. Crime scenes

                                     5. Alcohol or drug use

                                     6. Weapons — If any kind of weapon is
                                        observed or suspected, notify the
                                        police immediately.

                                     7. Family members

                                     8. Bystanders — In some cases it may
                                        be necessary to place the patient in
                                        the ambulance and leave the scene
                                        rather than wait for the police.

                                     9. Perpetrators

                                     10. Pets

                               D. React

                                     1. Retreat

                                          a. Flee

                                               i.   Get far enough away to have
                                                    enough time to react should
                                                    the danger begin to move
                                                    toward the new position.

                                               ii. Place two major obstacles
                                                   between self and the danger.


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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     b. Get rid of any cumbersome
                                        equipment.

                                     c. Take cover and conceal.

                                2. Radio

                                     a. Call for police assistance.

                                     b. Warn other responding units of
                                        the danger.

                                     c. Advise the dispatcher of the
                                        exact nature and location of the
                                        problem.

                                     d. Specify how many people are
                                        involved and whether or not
                                        weapons were observed.

                                3. Reevaluate

                                     a. Be aware that where violence
                                        has been, it may begin again.

                                     b. Maintain a level of alert
                                        observation throughout the call.

                                     c. If weapons or drugs are found,
                                        stop and radio police
                                        immediately. This may cause
                                        delays in reaching the patient,
                                        but is necessary.




Fire Protection Publications                                                       21-36
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Firefighter I                             Basic Pre-Hospital Emergency Medical Care for Firefighters




Section V: Introduction to Basic Cardiac Life Support                                   40 min.

                               V.    INTRODUCTION TO BASIC
                                     CARDIAC LIFE SUPPORT
                               Instructor Note: The purpose of this section is to
                               introduce students to the circulatory system and the
                               actions to be taken before resuscitation can occur.

pp. 1022-1024                  Objective 13 — Discuss the circulatory
                               system.
                                     A.    The circulatory system

                                           1. Delivers oxygen and nutrients to the
                                              body’s tissues

                                           2. Removes waste from the tissues

                                           3. Heart

                                                a. A hollow, muscular organ about
                                                   the size of a fist

                                                b. Lies in the lower left central
                                                   region of the chest between the
                                                   lungs

                                                c. Protected in the front by the ribs
                                                   and sternum

                                                d. Protected in the back by the
                                                   spinal column




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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                                          e. Contains four chambers

                                               i.   Two upper chambers — Left
                                                    and right atria

                                               ii. Two lower chambers — Left
                                                   and right ventricles

                                     4. Blood vessels — Transport blood
                                        throughout the body

                                     5. Arteries — Transport blood away
                                        from the heart

                                     6. Veins — Carry blood back to the
                                        heart

                                     7. Capillaries — Allow for the exchange
                                        of gases and nutrients between the
                                        blood and the cells of the body

                                     8. Blood

                               B.    How the heart works

                                     1. The heart is a two-sided pump.

                                     2. The left side receives oxygenated
                                        blood from the lungs and then
                                        pumps it to all parts of the body.

                                     3. The right side receives
                                        deoxygenated blood from the body
                                        and then pumps it into the lungs.

                                     4. In the lungs, the blood will pick up
                                        incoming oxygen and release carbon
                                        dioxide for exhalation.




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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     5. Blood is kept under pressure and in
                                        constant circulation by the heart’s
                                        pumping action.

                                     6. Pulse

                                          a. A sign of the pressure exerted
                                             during each contraction of the
                                             heart

                                          b. Is an indication of the wave of
                                             blood sent through the arteries
                                             when the heart pumps

                                          c. Can be most easily felt where the
                                             large artery lies over a bone
                                             close to the skin

                                               i.   Carotid pulse in the neck

                                               ii. Brachial pulse in the
                                                   underside of the upper arm

                                               iii. Radial pulse in the thumb side
                                                    of the wrist

                                               iv. Femoral pulse in the upper
                                                   thigh

                               C.    How the heart stops

                                     1. Respiratory arrest and cardiac arrest

                                          a. Immediate CPR slows the death
                                             process and is critical to patient
                                             survival.

                                          b. However, if a patient is clinically
                                             dead for 4 to 6 minutes, brain
                                             cells begin to die.


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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



                                               c. After 8 to 10 minutes without a
                                                  pulse, irreversible damage occurs
                                                  to the brain, regardless of how
                                                  well CPR is performed.

                                          2. Reasons

                                               a. Heart disease

                                               b. Stroke

                                               c. Allergic reaction

                                               d. Prolonged seizures

                                               e. Other medical conditions

                                               f. Serious injury

pp. 1024-1025                  Objective 14 — List the links in the
                               chain of survival.
                                    A.    The patient in respiratory and
                                          cardiac arrest has the best chance
                                          of surviving if all of the links in the
                                          chain of survival come together.

                                    B.    Early access — Lay people must
                                          activate EMS immediately.

                                    C.    Early CPR — Family members,
                                          citizens, and firefighters must be
                                          trained in CPR and begin as soon as
                                          possible.




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



                                    D. Early defibrillation

                                          1. The process by which an electrical
                                             current is sent to the heart to correct
                                             fatal heart rhythms

                                          2. The earlier defibrillation can be
                                             performed the more likely the
                                             survival of the patient.

                                    E.    Early advanced care — The
                                          administration of medications and
                                          other advanced therapies; can be
                                          done by paramedics or by prompt
                                          transportation to the emergency
                                          department

pp. 1025-1030                  Objective 15 — Explain actions to be
                               taken before resuscitation.
                                    A.    Assess the patient.

                                          1. Determine unresponsiveness.

                                               a. Ask ―Are you okay?‖

                                               b. If unresponsive:

                                                    i.   Activate EMS.

                                                    ii. Position patient.




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters




                               Ask Students: Where should patients be
                               positioned?


                               Briefly discuss the answers with students. Explain
                               that patients should be positioned in an area that is
                               large enough for all personnel and equipment, and
                               that patients should be moved to a hard, flat
                               surface if possible.

                                          2. Determine breathlessness.

                                               a. If no breathing, provide 2
                                                  ventilations.

                                               b. Special considerations

                                                    i.   If breathing is present,
                                                         continue care as necessary.

                                                    ii. If first ventilation is
                                                        unsuccessful, reposition head
                                                        and try again.

                                                    iii. If ventilations are still
                                                         unsuccessful, follow airway
                                                         obstruction clearance
                                                         procedures.

                                          3. Determine pulselessness.

                                               a. If no pulse, begin chest
                                                  compressions.

                                               b. Special considerations

                                                    i.   In an infant, feel for brachial
                                                         pulse.


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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                                               ii. If pulse is present but
                                                   breathing is absent, continue
                                                   rescue breathing.

                                               iii. In infants and children with
                                                    pulse less than 60/min, begin
                                                    chest compressions.

                                     4. Assess the ABC’s

                                          a. Is the patient’s airway open?

                                          b. Is the patient breathing?

                                          c. Does the patient have circulation
                                             of blood (a pulse)?

                               B.    Activate EMS

                                     1. If assistance is available, have
                                        someone else call 9-1-1 or EMS as
                                        soon as a patient collapses or is
                                        discovered in collapse.

                                     2. If alone

                                          a. Adult — First determine
                                             unresponsiveness and then
                                             activate EMS before returning to
                                             the patient to initiate the next
                                             steps.

                                          b. Child or infant — Perform 2
                                             minutes of resuscitation before
                                             activating EMS.




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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                               C.    Position the patient.

                                     1. Make sure that the patient is lying
                                        supine (on back) before attempting
                                        to open the airway and assess
                                        breathing and circulation.

                                     2. If injury is suspected, support the
                                        patient’s neck and hold the head still
                                        and in line with the spine while
                                        moving, assessing, and caring for
                                        the patient.

                               D. Open the airway.

                                     1. Most airway problems are caused by
                                        the tongue. Two procedures can
                                        help to correct the position of the
                                        tongue and thus open the airway.

                                     2. Head-tilt, chin-lift maneuver

                                          a. Provides for maximum opening of
                                             the airway

                                          b. Useful on all patients who need
                                             assistance in maintaining an
                                             airway or breathing

                                          c. One of the best methods for
                                             correcting obstructions caused by
                                             the tongue

                                          d. Should be used only on a patient
                                             that is certain to have not
                                             suffered a spinal injury




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Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



                                     e. Steps

                                          i.   Once the patient is supine,
                                               place one hand on the
                                               forehead and the fingertips of
                                               the other hand under the
                                               bony area at the center of the
                                               patient’s lower jaw.

                                          ii. Tilt the head by applying
                                              gentle pressure to the
                                              patient’s forehead.

                                          iii. Use fingertips to lift the chin
                                               and support the lower jaw.
                                               Move the jaw forward to a
                                               point where the lower teeth
                                               are almost touching the upper
                                               teeth. Do not compress the
                                               soft tissues under the lower
                                               jaw, which can press and
                                               close off the airway.

                                          iv. Do not allow the patient’s
                                              mouth to close. To provide an
                                              adequate opening at the
                                              mouth, use the thumb of the
                                              hand supporting the chin to
                                              pull back the patient’s lower
                                              lip. For safety (to prevent
                                              being bitten), do not insert
                                              thumb into the patient’s
                                              mouth.




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Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters



                                          3. Jaw-thrust maneuver

                               Instructor Note: Explain to students that the
                               responder doing the jaw-thrust maneuver will not
                               be able to perform any other tasks without
                               compromising the patient’s airway.

                                               a. Most commonly used to open the
                                                  airway of an unconscious patient
                                                  with suspected head, neck, or
                                                  spinal injuries.

                               Instructor Note: Emphasize that the jaw-thrust
                               maneuver is the only widely recommended
                               procedure for use on patients with possible head,
                               neck, or spinal injuries.

                                               b. Steps

                                                    i.   Carefully keep the patient’s
                                                         head, neck, and spine
                                                         aligned, moving the patient
                                                         as a unit as placing him or
                                                         her in the supine position.

                                                    ii. Kneel at the top of the
                                                        patient’s head. For greater
                                                        comfort, rest elbows on the
                                                        same surface the patient is
                                                        lying on.

                                                    iii. Reach forward and gently
                                                         place one hand on each side
                                                         of the patient’s lower jaw, at
                                                         the angles of the jaw below
                                                         the ears.




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Firefighter I                       Basic Pre-Hospital Emergency Medical Care for Firefighters



                                               iv. Help to stabilize the patient’s
                                                   head by using wrists or
                                                   forearms.

                                               v. Using index fingers, push the
                                                  angles of the patient’s lower
                                                  jaw forward.

                                               vi. Retract the patient’s lower lip
                                                   with the thumb to keep the
                                                   mouth open.

                                               vii. Do not tilt or rotate the
                                                    patient’s head. REMEMBER,
                                                    THE PURPOSE OF THE JAW-
                                                    THRUST MANEUVER IS TO
                                                    OPEN THE AIRWAY
                                                    WITHOUT MOVING THE
                                                    HEAD OR NECK.

                               E.    Initial ventilations and pulse check

                                     1. Deliver 2 breaths, each delivered
                                        over 1 second and/or sufficient
                                        volume to make the chest rise.

                                     2. If the first breath is unsuccessful,
                                        reposition the patient’s head before
                                        attempting the second breath.

                                     3. If the second ventilation is
                                        unsuccessful, assume that there is a
                                        foreign-body airway obstruction and
                                        perform airway clearance
                                        techniques.

                                     4. If the initial ventilations are
                                        successful, confirm an open airway
                                        and feel for a pulse.


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                                           5. If the patient has no pulse, begin
                                              chest compressions with ventilations.

                                           6. If the patient has a pulse but
                                              breathing is absent or inadequate,
                                              perform rescue breathing.


Section VI: Rescue Breathing                                                            15 min.

                               VI.   RESCUE BREATHING
                               Instructor Note: The purpose of this section is to
                               discuss rescue breathing for adults, children, and
                               infants.

p. 1030                        Objective 16 — Discuss rescue
                               breathing.
                                     A.    Rescue breathing

                                           1. Adult

                                                a. Puberty and older

                                                b. Ventilation duration — 1/second

                                                c. Ventilation rate — 10-12
                                                   breaths/minute

                                           2. Child

                                                a. 1 year-puberty

                                                b. Ventilation duration — 1/second

                                                c. Ventilation rate — 12-20
                                                   breaths/minute




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                                3. Infant

                                     a. Birth-1 year

                                     b. Ventilation duration — 1/second

                                     c. Ventilation rate — 12-20
                                        breaths/minute

                                4. Gastric distention

                                     a. Rescue breathing can force air
                                        into the patient’s stomach,
                                        causing the stomach to become
                                        distended.

                                     b. This may indicate that the airway
                                        is blocked, that there is improper
                                        head position, or that the
                                        ventilations being provided are
                                        too large or too quick to be
                                        accommodated by the lungs or
                                        the trachea.

                                     c. Can cause serious problems

                                          i.   The air-filled stomach reduces
                                               lung volume by forcing the
                                               diaphragm upward.

                                          ii. Regurgitation or vomiting is a
                                              strong possibility.

                                     d. How to avoid

                                          i.   Position the patient’s head
                                               properly.

                                          ii. Avoid too forceful and too
                                              quickly delivered ventilations.


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Firefighter I                              Basic Pre-Hospital Emergency Medical Care for Firefighters



                                                      iii. Limit the volume of
                                                           ventilations delivered.

                               Instructor Note: Discuss that another way to
                               avoid gastric distention is by applying cricoid
                               pressure – pressure on the cricoid cartilage, found
                               near the Adam’s apple on the neck. If a responder
                               is free, they should apply downward pressure on
                               the cricoid cartilage, forcing the airway down and
                               closing off the esophagus.

Section VII: CPR                                                                         30 min.

                               VII. CPR
                               Instructor Note: The purpose of this section is to
                               describe the basic steps of CPR and the specific
                               steps for performing CPR on adults, children, and
                               infants.

pp. 1031-1035                  Objective 17 — Describe the steps of
                               cardiopulmonary resuscitation (CPR).
                                      A.    Checking for circulation

                                            1. Before beginning CPR, confirm that
                                               the patient is pulseless.

                                            2. If an adult patient is pulseless, begin
                                               CPR.

                                            3. If an infant or child has a pulse
                                               slower than 60 beats per minute,
                                               begin CPR.

                               Instructor Note: Stress that responders are not to
                               initiate CPR on any adult who has a pulse.



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                                      B.    Providing chest compressions

                                            1. Place the patient supine on a hard
                                               surface.

                                            2. Position hands properly on the CPR
                                               compression site.

                                            3. Straighten arms and lock elbows.

                                            4. Make certain that shoulders are
                                               directly over hands (directly over the
                                               patient’s sternum).

                                                 a. Be sure that hands are
                                                    sufficiently above the xiphoid
                                                    process at the bottom tip of the
                                                    sternum.

                                                 b. Pressing down on this piece of
                                                    cartilage may break it, puncturing
                                                    the liver below.

                                            5. Deliver compressions STRAIGHT
                                               DOWN, with enough force to
                                               depress the sternum of a typical
                                               adult 1½ to 2 inches (38 mm to 50
                                               mm).

                               Instructor Note: Emphasize that correct CPR will
                               often break the patient’s ribs. If this happens, the
                               responder should check that correct hand
                               placement is being used and continue CPR.




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                                     6. Fully release pressure on the
                                        patient’s sternum, but do NOT bend
                                        elbows and do NOT lift hands from
                                        the sternum.

                                          a. Compressions should be
                                             delivered in a rhythmic fashion.

                                          b. The amount of time spent
                                             compressing should be the same
                                             as the time for the release.

                               C.    How to join CPR in progress

                                     1. If CPR has been started by someone
                                        who is trained to perform CPR but is
                                        not part of the EMS system, and a
                                        responder joins this person to
                                        perform CPR, the responder should:

                                          a. Identify themselves as someone
                                             who knows CPR and ask to help.

                                          b. Ensure that EMS has been
                                             activated.

                                          c. Allow the first rescuer to
                                             complete a cycle of 30
                                             compressions and 2 ventilations.

                                          d. Check for a pulse. If there is no
                                             pulse, start one-rescuer CPR. If
                                             the responder tires before EMS
                                             arrives, he or she should let the
                                             other rescuer perform CPR.
                                             Alternate until EMS arrives.




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                                2. If joining another member of the
                                   EMS system who has initiated CPR,
                                   the responder should:

                                     a. Identify themselves and their
                                        level training, and state that they
                                        are ready to perform two-rescuer
                                        CPR.

                                     b. While the first rescuer is
                                        providing compressions, spend 5
                                        seconds checking for a carotid
                                        pulse produced by each
                                        compression.

                                          i.   This is to determine if the
                                               compressions being delivered
                                               are effective.

                                          ii. Inform the first rescuer if
                                              there is or is not a pulse
                                              being produced.

                                     c. Say, ―Stop compressions,‖ and
                                        check for spontaneous pulse and
                                        breathing.

                                     d. If there is no pulse, state, ―No
                                        pulse. Continue CPR.‖

                                     e. The first rescuer resumes
                                        compressions, and the second
                                        rescuer provides two ventilations
                                        during a pause after every
                                        thirtieth compression (fifteenth in
                                        a child or infant).




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pp. 1034-1036                  Objective 18 — Describe the CPR
                               techniques for an infant patient.
                                    A.    CPR for an infant patient

                                          1. Age — Birth – 1 year

                                          2. Compression depth — 1/3 to ½
                                             depth of chest (using two fingers)

                                          3. Compression rate — 100/minute
                                             (Newborn 120/minute)

                                          4. Each ventilation — 1 second

                                          5. Pulse check location — Brachial
                                             artery

                                          6. One-rescuer CPR compressions-to-
                                             ventilations ratio — 30:2 (alone);
                                             15:2 (2 rescuers); 3:1 (newborn)

                                          7. When working alone, call 9-1-1 or
                                             emergency dispatcher — After
                                             establishing unresponsiveness and 2
                                             minutes of resuscitation unless heart
                                             disease patient




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pp. 1034-1036                  Objective 19 — Describe the CPR
                               techniques for a child patient.
                                    A.    CPR for a child patient

                                          1. Age — 1 year – puberty

                                          2. Compression depth — 1/3 to ½
                                             depth of chest (using one hand)

                                          3. Compression rate — 100/minute

                                          4. Each ventilation — 1 second

                                          5. Pulse check location — Carotid artery

                                          6. One-rescuer CPR compressions-to-
                                             ventilations ratio — 30:2

                                          7. When working alone, call 9-1-1 or
                                             emergency dispatcher — After
                                             establishing unresponsiveness and 2
                                             minutes of resuscitation unless heart
                                             disease patient

pp. 1034-1036                  Objective 20 — Describe the CPR
                               techniques for an adult patient.
                                    A.    CPR for an adult patient

                                          1. Age — Puberty and older

                                          2. Compression depth — 1½ to 2
                                             inches

                                          3. Compression rate — 100/minute

                                          4. Each ventilation — 1 second

                                          5. Pulse check location — Carotid artery


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                                          6. One-rescuer CPR compressions-to-
                                             ventilations ratio — 30:2

                                          7. When working alone, call 9-1-1 or
                                             emergency dispatcher — After
                                             establishing unresponsiveness;
                                             before beginning resuscitation unless
                                             submersion, injury, or overdose

pp. 1035-1036                  Objective 21 — Discuss indications of
                               effective CPR and when CPR may be
                               interrupted.
                                    A.    How to know if CPR is effective

                                          1. Have someone else feel for a carotid
                                             pulse

                                          2. Listen for exhalation of air

                                          3. Other indications

                                               a. Pupils constrict.

                                               b. Skin color improves.

                                               c. Heartbeat returns spontaneously.

                                               d. Spontaneous, gasping
                                                  respirations are made.

                                               e. Arms and legs move.

                                               f. Swallowing is attempted.

                                               g. Consciousness returns.




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                                   B.    Interrupting CPR

                                         1. Once CPR has begun, the process
                                            may be interrupted for no more than
                                            a few seconds to check for pulse and
                                            breathing or to reposition self and
                                            the patient.

                                         2. In addition, CPR may be interrupted
                                            to:

                                              a. Move a patient onto a stretcher

                                              b. Move a patient down a flight or
                                                 stairs or through a narrow
                                                 doorway or hallway

                                              c. Move a patient on or off the
                                                 ambulance

                                              d. Suction to clear vomitus or
                                                 airway obstructions

                                              e. Allow for defibrillation or
                                                 advanced cardiac life support
                                                 measures to be initiated

p. 1037                        Objective 22 — Summarize when not to
                               begin or to terminate CPR.
                                   A.    When not to begin or to terminate
                                         CPR

                                         1. Obvious mortal wounds

                                              a. Decapitation

                                              b. Incineration

                                              c. A severed body


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                                          d. Severe injuries that permit CPR
                                             from being effectively performed

                                     2. Rigor mortis — Stiffening of the body
                                        and its limbs that occurs after death

                                     3. Obvious decomposition

                                     4. A line of lividity

                                          a. Red or purple skin discoloration
                                             that occurs when gravity causes
                                             the blood to sink to the lowest
                                             parts of the body and collect
                                             there

                                          b. Indicates that the patient has
                                             been dead for more than 15
                                             minutes

                                     5. Stillbirth

                               B.    Once CPR has been started, it must
                                     continue until:

                                     1. Spontaneous circulation occurs; then
                                        provide rescue breathing as needed.

                                     2. Spontaneous circulation and
                                        breathing occur

                                     3. Another trained rescuer can take
                                        over

                                     4. Care of the patient has been turned
                                        over to a person with a higher level
                                        of training

                                     5. The responder is too exhausted to
                                        continue


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                                           6. The responder receives a ―no CPR‖
                                              order from a physician or other
                                              authority per local protocols


Section VIII: Clearing Airway Obstructions                                              25 min.

                               VIII. CLEARING AIRWAY
                                     OBSTRUCTIONS
                               Instructor Note: The purpose of this section is to
                               describe the steps to be taken in order to clear an
                               airway obstruction.

pp. 1037-1041                  Objective 23 — Summarize actions
                               taken when clearing an airway
                               obstruction.
                                     A.    Types of airway obstruction

                                           1. Partial (mild) — If the patient can
                                              speak or cough

                                                a. Have the patient cough; a strong
                                                   and forceful cough indicates an
                                                   exchange of air.

                                                b. Continue to encourage the
                                                   patient to cough in the hope that
                                                   such action will dislodge or expel
                                                   the foreign object.

                                           2. Complete (severe)

                                                a. The conscious patient with a
                                                   severe airway obstruction will try
                                                   to speak but will not be able to.




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                                          b. The unconscious patient with a
                                             severe airway obstruction will be
                                             in respiratory arrest.

                               B.    Abdominal thrusts

                                     1. Use the following procedures for the
                                        conscious adult or child (not infant)
                                        who is standing or sitting

                                          a. Make a fist, and place the thumb
                                             side of this fist against the
                                             midline of the patient’s abdomen
                                             between waist and rib cage.

                                          b. Grasp properly positioned fist
                                             with the other hand and apply
                                             pressure inward and up toward
                                             the patient’s head in a smooth,
                                             quick movement. Continue to
                                             deliver thrusts until the foreign
                                             body is dislodged.

                                     2. Use the following procedures for the
                                        unconscious adult or child (not
                                        infant) or for a conscious patient
                                        who cannot sit or stand, or if the
                                        responder is too short to reach
                                        around the patient to deliver thrusts.

                                          a. Place the patient in a supine
                                             position and begin CPR.

                                          b. Every time the airway is opened,
                                             look in the mouth for an object.




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                                          c. If, and only if, an object is seen,
                                             remove it by sweeping fingers in
                                             the patient’s mouth from one
                                             side to the other.

                               C.    Chest thrusts

                                     1. Used in place of abdominal thrusts
                                        when the patient is in the late stages
                                        of pregnancy, or when the patient is
                                        too obese for abdominal thrusts to
                                        be effective

                                     2. For the conscious adult who is
                                        standing or sitting

                                          a. Position self behind the patient
                                             and slide arms under his armpits,
                                             so that his chest is encircled.

                                          b. Form a fist with one hand, and
                                             place the thumb side of this fist
                                             on the midline of the sternum
                                             about 2 or 3 finger widths above
                                             the xiphoid process. This places
                                             the fist on the lower half of the
                                             sternum but not in contact with
                                             the edge of the rib cage.

                                          c. Grasp fist with the other hand
                                             and deliver 5 chest thrusts
                                             directly backward of the spine.

                                     3. For the unconscious adult

                                          a. Place the patient in a supine
                                             position.

                                          b. Perform CPR.


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                                       c. Every time the airway is opened,
                                          look in the mouth for an object.

                                       d. If, and only if, an object is seen,
                                          remove it by sweeping fingers in
                                          the patient’s mouth from one
                                          side to the other.

                               D. Airway clearance sequences

                                  1. Conscious adult

                                       a. Ask, ―Are you choking?‖

                                       b. Heimlich maneuver until
                                          obstruction is relieved or patient
                                          loses consciousness.

                                  2. Unconscious adult

                                       a. Establish unresponsiveness.

                                       b. If alone, call for help.

                                       c. Open airway.

                                       d. Attempt to ventilate.

                                       e. If unsuccessful, reposition head
                                          and attempt to ventilate again.

                                       f. If unsuccessful, perform CPR.

                                       g. Remove objects from the mouth
                                          if they become visible.




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                                3. Conscious child

                                     a. Ask, ―Are you choking?‖

                                     b. Heimlich maneuver until
                                        obstruction is relieved or patient
                                        loses consciousness.

                                4. Unconscious child

                                     a. Establish unresponsiveness.

                                     b. Open airway.

                                     c. Attempt to ventilate.

                                     d. If unsuccessful, reposition head
                                        and attempt to ventilate again.

                                     e. If unsuccessful, perform CPR.

                                     f. Remove visible objects (NO blind
                                        sweeps).

                                     g. After 2 minutes, call for help.

                                5. Conscious infant

                                     a. Observe signs of choking.

                                     b. Series of 5 back blows and 5
                                        chest thrusts.

                                6. Unconscious infant

                                     a. Establish unresponsiveness.

                                     b. Open airway.

                                     c. Attempt to ventilate.




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                                                d. If unsuccessful, reposition head
                                                   and attempt to ventilate again.

                                                e. If unsuccessful, perform CPR.

                                                f. Remove visible objects (NO blind
                                                   sweeps).

                                                g. After 2 minutes, call for help.

                                     E.    Procedures for a child or an infant

                                           1. Place the infant facedown on arm.

                                           2. Be sure to support the infant’s head
                                              with hand.

                               Instructor Note: Remind students that the
                               infant’s head should be lower than the body in
                               order to allow gravity to assist them.

                                           3. Deliver five back slaps in between
                                              the shoulder blades with the heel of
                                              hand.

                                           4. While taking care to support the
                                              head, move the infant over to other
                                              hand in a way that results in his
                                              being face up.

                                           5. Using the same technique as chest
                                              compressions, deliver five chest
                                              thrusts.

                                           6. Repeat this procedure as required,
                                              until either the object is dislodged or
                                              the infant becomes unconscious.




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Section IX: Bleeding Control                                                             40 min.

                               IX.    BLEEDING CONTROL
                               Instructor Note: The purpose of this section is to
                               discuss the main components of the circulatory
                               system and explain the steps for controlling external
                               bleeding. Internal bleeding is also discussed.

p. 1041                        Objective 24 — Describe the main
                               components of the circulatory system.
                                      A.    Heart

                                            1. A muscular organ that lies within the
                                               chest, behind the sternum

                                            2. Pumps blood, which supplies oxygen
                                               and nutrients to the cells of the body

                                            3. Must pump at an adequate rate and
                                               rhythm in order to provide a
                                               sufficient supply of oxygen and
                                               nutrients to all parts of the body

                                      B.    Blood vessels

                                            1. Arteries

                                                 a. Carry oxygen-rich blood away
                                                    from the heart

                                                 b. Are under a great deal of
                                                    pressure during the heart’s
                                                    contractions




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                                               c. Have a thick, muscular wall that
                                                  enable them to dilate or
                                                  constrict, depending on the need
                                                  for oxygen and nutrients

                                          2. Capillaries

                                               a. Take blood from the arteries

                                               b. Supply blood to every cell of the
                                                  body

                                          3. Veins

                                               a. Carry blood to the heart

                                               b. Have one-way valves that
                                                  prevent blood from flowing in the
                                                  wrong direction

                                    C.    Blood

pp. 1042-1043                  Objective 25 — Differentiate between
                               arterial, venous, and capillary bleeding.
                                    A.    Arterial bleeding

                                          1. Is bright red in color because it is
                                             still rich in oxygen

                                          2. Is often rapid and profuse, spurting
                                             with each heartbeat

                                          3. Is the most difficult bleeding to
                                             control




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                                    B.    Venous bleeding

                                          1. Is usually dark red or maroon in
                                             color

                                          2. Has a steady flow

                                          3. Is usually easy to control

                                    C.    Capillary bleeding

                                          1. Is usually slow and ―oozing‖

                                          2. Is usually considered minor and is
                                             easily controlled

                                          3. Often clots spontaneously, or with
                                             minimal treatment

                                          4. Is usually somewhere between
                                             bright red and dark red

                                          5. Usually results from a minor injury
                                             such as a scrape

pp. 1043-1048                  Objective 26 — Describe the steps for
                               controlling external bleeding.
                                    A.    Direct pressure — The most
                                          common and effective way to
                                          control external bleeding

                                          1. Apply pressure to the wound until
                                             bleeding is controlled. If the bleeding
                                             is mild, use a sterile dressing. If the
                                             bleeding is severe or spurting,
                                             immediately place gloved hand
                                             directly on the wound. Do not waste
                                             time trying to find a dressing.



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                                           2. Hold the pressure firmly until the
                                              bleeding is controlled. Remember
                                              the goal of limiting additional blood
                                              loss.

                                           3. Once the bleeding has been
                                              controlled, bandage a dressing firmly
                                              in place to form a pressure dressing.

                                           4. Never remove a dressing once it has
                                              been placed on the wound. Removal
                                              of a dressing may destroy clots or
                                              cause further injury to the site. If a
                                              dressing becomes blood soaked,
                                              apply additional dressings on top of
                                              it and hold them firmly in place.
                                              Continue holding direct pressure on
                                              the wound until arrival at the
                                              hospital.

                               Instructor Note: Explain that a blood pressure
                               cuff can be used to keep pressure on a wound in
                               order to free a responder.

                                     B.    Elevation

                                           1. When an injury is elevated above the
                                              level of the heart, gravity helps
                                              reduce the blood pressure in the
                                              extremity, slowing bleeding.

                                           2. Do not use this method if possible
                                              musculoskeletal injuries, impaled
                                              objects in the extremity, or spine
                                              injury are suspected.




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                                     3. Apply direct pressure to the injury
                                        site and elevate the injured
                                        extremity, keeping the injury site
                                        above the level of the heart.

                               C.    Pressure points

                                     1. A site where a large artery lies close
                                        to the surface of the body and
                                        directly over a bone

                                     2. Should be used only after direct
                                        pressure and elevation have failed

                                     3. For bleeding from an upper
                                        extremity, apply pressure to a point
                                        over the brachial artery. To find the
                                        artery:

                                          a. Hold the patient’s arm out at a
                                             right angle to the body with the
                                             palm of the hand facing up. Do
                                             not use force to raise the arm if
                                             the movement causes pain or
                                             may aggravate an injury. If it is
                                             not possible to raise the arm this
                                             far, leave the arm in the position
                                             in which it was found.

                                          b. Locate the groove between the
                                             biceps muscle and the upper arm
                                             bone (humerus) about midway
                                             between the elbow and armpit.
                                             Cradle the upper arm in the palm
                                             of the hand and position fingers
                                             in this medial groove.




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                                        c. Compress the artery against the
                                           underlying bone by pressing
                                           finger into the groove. If
                                           pressure is properly applied, no
                                           radial pulse should be felt.

                                   4. For bleeding from a lower extremity,
                                      apply pressure to a point over the
                                      femoral artery.

                                        a. Locate the femoral artery on the
                                           medial side of the anterior thigh
                                           where it joins the lower trunk of
                                           the body.

                                        b. Feel for a pulse at a point just
                                           below the groin.

                                        c. Place the heel of the hand over
                                           the site and apply pressure
                                           toward the bone until the
                                           bleeding is controlled.

                               D. Special situations involving
                                  bleeding

                                   1. Head injury

                                        a. May cause bleeding or loss of
                                           cerebrospinal fluid (CSF) from
                                           the ears or nose

                                        b. Do not attempt to stop this
                                           bleeding or fluid loss – doing so
                                           may increase the pressure in the
                                           skull.

                                        c. Allow the drainage to flow freely,
                                           using a gauze pad to collect it.


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                                          2. Nosebleed

                                               a. Have the patient sit down and
                                                  lean forward.

                                               b. Apply or instruct the patient to
                                                  apply direct pressure to the
                                                  fleshy portion around the nostrils.

                                               c. Keep the patient calm and quiet.

                                               d. Do not let the patient lean back.

                                               e. If the patient becomes
                                                  unconscious or is unable to
                                                  control his own airway, place the
                                                  patient in the recovery position
                                                  (on his side) and be prepared to
                                                  provide suction and aggressive
                                                  airway management.

pp. 1048-1050                  Objective 27 — Discuss internal
                               bleeding.
                                    A.    Internal bleeding

                                          1. Bleeding that occurs inside the body

                                          2. Can be very serious because:

                                               a. Damage to the internal organs
                                                  and large blood vessels can
                                                  result in loss of a large quantity
                                                  of blood in a short period of time.

                                               b. Blood loss cannot be seen.

                                               c. Severe internal blood loss may
                                                  even occur from injuries to the
                                                  extremities.


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                                3. Can be caused by blunt trauma,
                                   including:

                                     a. Falls

                                     b. Motor-vehicle or motorcycle
                                        crashes

                                     c. Auto-pedestrian collisions

                                     d. Blast injuries

                                4. May also be caused by penetrating
                                   trauma, such as:

                                     a. Gunshot wounds

                                     b. Stab wounds from a knife, ice
                                        pick, screwdriver, or similar
                                        object

                                     c. Impaled objects

                                5. Signs of internal bleeding

                                     a. Injuries to the surface of the
                                        body, which could indicate
                                        underlying injuries

                                     b. Bruising, swelling, or pain over
                                        vital organs

                                     c. Painful, swollen, or deformed
                                        extremities

                                     d. Bleeding from the mouth,
                                        rectum, vagina, or other body
                                        orifice

                                     e. A tender, rigid, or distended
                                        abdomen


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                                     f. Vomiting a coffee-ground-like
                                        substance or bright red vomitus,
                                        indicating the presence of blood

                                     g. Dark, tarry stools or bright red
                                        blood in the stool

                                     h. Signs and symptoms of shock

                                6. Care for the patient with internal
                                   bleeding

                                     a. Maintain the ABCs and provide
                                        support as needed.

                                     b. If are trained to do so and it is
                                        permitted by the organization,
                                        administer high-concentration
                                        oxygen by nonrebreather mask if
                                        oxygen administration has not
                                        already begun.

                                     c. Control any external bleeding.

                                     d. Provide prompt transport to an
                                        appropriate medical facility.
                                        Internal bleeding must often be
                                        controlled in the operating room.




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Section XI: Shock                                                                       15 min.

                               X.    SHOCK
                               Instructor Note: The purpose of this section is to
                               describe the types of shock and explain the steps
                               for managing shock.

pp. 1050-1051                  Objective 28 — Describe types of shock.
                                     A.    Shock

                                           1. Inadequate tissue perfusion

                                           2. The inability of the circulatory
                                              system to supply cells with oxygen
                                              and nutrients

                                     B.    Hypovolemic shock

                                           1. Is the type most commonly seen by
                                              EMT-Bs

                                           2. Bleeding can be internal, external, or
                                              both

                                           3. May be caused by burns or crush
                                              injuries, where plasma is lost

                                     C.    Cardiogenic shock

                                           1. May be suffered by patients
                                              suffering a heart attack

                                           2. May be caused by slow, fast, or
                                              irregular heartbeat

                                           3. May be caused by other cardiac
                                              problems

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                                    D. Neurogenic/vasodilatory shock

                                          1. Results from the uncontrolled
                                             dilation of blood vessels due to nerve
                                             paralysis caused by spinal cord
                                             injuries

                                          2. May be caused by sepsis or an
                                             anaphylactic reaction

                                          3. Is only seen occasionally in the field

p. 1052                        Objective 29 — Describe the signs of
                               shock.
                                    A.    Altered mental status

                                          1. Caused by deprivation of oxygen

                                          2. Anxiety

                                          3. Restlessness

                                          4. Combativeness

                                    B.    Pale, cool, clammy skin — Blood
                                          may be diverted from non-vital
                                          areas to the vital organs

                                    C.    Nausea and vomiting

                                    D. Vital sign changes

                                          1. Pulse will increase in an attempt to
                                             pump more blood.

                                          2. Respirations increase in an attempt
                                             to raise the oxygen saturation of the
                                             blood left in the system.




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                                          3. Blood pressure drops because the
                                             body’s compensating mechanisms
                                             can no longer keep up with the
                                             decrease in perfusion or blood loss.

                                    E.    Other signs

                                          1. Thirst

                                          2. Dilated pupils

                                          3. Cyanosis — Blue or gray color
                                             resulting from lack of oxygen

p. 1053                        Objective 30 — Describe the steps for
                               managing shock.
                                    A.    Managing shock

                                          1. Maintain an open airway and assess
                                             the respiratory rate.

                                          2. Assist ventilations or perform CPR if
                                             necessary. If the patient is breathing
                                             adequately, apply high-concentration
                                             oxygen by nonrebreather mask if
                                             trained to do so and allowed by the
                                             organization.

                                          3. Control any external bleeding.

                                          4. If there is no possibility of spine
                                             injury, elevate the legs 8 to 12
                                             inches (200 mm to 300 mm).

                                          5. Prevent loss of body heat by
                                             covering the patient with a blanket.

                                          6. Transport the patient immediately.



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                                           7. If the patient is conscious, speak
                                              calmly and reassuringly throughout
                                              assessment, care, and transport.


Section XI: Summary and Review                                                          15 min.

                               XI.   SUMMARY AND REVIEW
                               Instructor Note: The purpose of this section is to
                               summarize the lesson and review key points.
                               Answer any questions students may have about the
                               lesson or course in general.

                                     A.    Chapter Summary

                                           1. Fire fighting is recognized as a
                                              dangerous profession. Many
                                              firefighters die from sudden cardiac
                                              events while on duty.

                                           2. The most effective strategy for
                                              ensuring prompt, well-trained
                                              emergency medical care is to train
                                              all firefighters in basic pre-hospital
                                              emergency medical care.

                                     B.    Review Questions

                                           1. What body substance isolation (BSI)
                                              precautions should firefighters take
                                              to protect against infection?

                                           2. What are three communicable
                                              diseases of concern to firefighters?

                                           3. What is the Ryan White CARE Act?




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                                4. What are some causes of stress for
                                   emergency responders?

                                5. What are the links in the chain of
                                   survival for patients in respiratory
                                   and cardiac arrest?

                                6. Describe what actions are taken
                                   when assessing the patient during
                                   CPR.

                                7. What are the basic steps in
                                   performing CPR?

                                8. What are the major methods of
                                   controlling external bleeding?

                                9. What are the emergency care steps
                                   for shock?




Fire Protection Publications                                                       21-78
Oklahoma State University
Firefighter I                            Basic Pre-Hospital Emergency Medical Care for Firefighters




                   Chapter 21 Quiz Answers
  1.     B
  2.     A
  3.     A
  4.     B
  5.     A
  6.     A
  7.     B
  8.     B
  9.     A
 10.     A
 11.     A
 12.     A
 13.     B
 14.     B
 15.     A
 16.     A
 17.     B
 18.     B
 19.     A
 20.     B
 21.     A
 22.     Answers should include any five of the following:
          The neighborhood while looking for house or building numbers
          The scene when approaching
          Violence
          Crime scenes
          Alcohol or drug use
          Weapons
          Family members
          Bystanders
          Perpetrators
          Pets


Fire Protection Publications                                                                 21-79
Oklahoma State University
Firefighter I                                  Basic Pre-Hospital Emergency Medical Care for Firefighters


 23.     Answers should include the following, in any order:
          Carotid pulse in the neck
          Brachial pulse in the underside of the upper arm
          Radial pulse in the thumb side of the wrist
          Femoral pulse in the upper thigh
 24.     Answers should include the following, in any order:
          Early access
          Early CPR
          Early defibrillation
          Early advanced care
 25.     Answers should include any four of the following:
          Feel for a carotid pulse
          Exhalation of air
          Pupils constrict.
          Skin color improves.
          Heartbeat returns spontaneously.
          Spontaneous, gasping respirations are made.
          Arms and legs move.
          Swallowing is attempted.
          Consciousness returns.
 26.     Answers should include any four of the following:
               Injuries to the surface of the body, which could indicate underlying injuries
               Bruising, swelling, or pain over vital organs
               Painful, swollen, or deformed extremities
               Bleeding from the mouth, rectum, vagina, or other body orifice
               A tender, rigid, or distended abdomen
               Vomiting a coffee-ground-like substance or bright red vomitus, indicating the
                presence of blood
               Dark, tarry stools or bright red blood in the stool
               Signs and symptoms of shock




Fire Protection Publications                                                                       21-80
Oklahoma State University
Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters




                   Chapter 21 Test Answers
Objective 1
  1.     A
  2.     A


Objective 2
  3.     C
  4.     C
  5.     D


Objective 3
  6.     B
  7.     A
  8.     A
  9.     A
 10.     B
 11.     A


Objective 4
 12.     A
 13.     D
 14.     C
 15.     B


Objective 5
 16.     D
 17.     B




Fire Protection Publications                                                       21-81
Oklahoma State University
Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



Objective 6
 18.     C
 19.     C
 20.     D


Objective 7
 21.     A
 22.     C


Objective 8
 23.     A


Objective 9
 24.     A
 25.     B


Objective 10
 26.     C


Objective 11
 27.     A
 28.     A


Objective 12
 29.     A
 30.     C
 31.     C




Fire Protection Publications                                                       21-82
Oklahoma State University
Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



Objective 13
 32.     B
 33.     C
 34.     A
 35.     B
 36.     C


Objective 14
 37.     C


Objective 15
 38.     D
 39.     A
 40.     C
 41.     D


Objective 16
 42.     A
 43.     C
 44.     B


Objective 17
 45.     A
 46.     A
 47.     A
 48.     D


Objective 18
 49.     A
 50.     C
 51.     A




Fire Protection Publications                                                       21-83
Oklahoma State University
Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



Objective 19
 52.     D
 53.     A
 54.     A


Objective 20
 55.     C
 56.     B
 57.     C


Objective 21
 58.     B
 59.     D


Objective 22
 60.     C
 61.     D


Objective 23
 62.     B
 63.     B
 64.     D


Objective 24
 65.     B
 66.     C


Objective 25
 67.     A
 68.     C
 69.     B




Fire Protection Publications                                                       21-84
Oklahoma State University
Firefighter I                  Basic Pre-Hospital Emergency Medical Care for Firefighters



Objective 26
 70.     B
 71.     D
 72.     A


Objective 27
 73.     D
 74.     D


Objective 28
 75.     C
 76.     D
 77.     C


Objective 29
 78.     C
 79.     D


Objective 30
 80.     A




Fire Protection Publications                                                       21-85
Oklahoma State University

				
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